Calgary Dentist, Smileworks - New Patients Welcome

New Patient Form

Please fill out this form and a member of our team will contact you within one business day.

If you already have an appointment booked with us, feel free to fill out our printable form and bring it with you to your initial appointment or you may email it us by filling out the form below prior to your visit.

*First Name: *Sur Name:

Address:

City: Province:

Postal Code: Country:

Birth Date:

Month: Day: Year:

Home Phone: Business Phone:

Cell Phone: Email:

Occupation: Referral Source:

Are you covered by a Dental Insurance Plan? Yes No

If yes, which company?

Medical History

Have you had or do you have any medical conditions?

Do you have any allergies to Medication? Yes No

If yes, to what medication are you allergic? Seperate medications with comma.

Do you require pre-medication prior to dental treatment? Yes No

If yes, what medication is required and for what reason?

Dental History

Please briefly describe your chief concern.

How does this affect you?

How long since your last dental visit?

When were your last dental x-rays?

How long since your last dental hygiene appointment?

Have you had any negative dental experiences in the past? If so, please describe.

Do you have any missing teeth? Yes No

Do you wear a denture or partial denture? Yes No

Do you have jaw joint pain? Yes No

Do you have clench or grind your teeth? Yes No

Do you have neck or back pain? Yes No

Do you have ringing in your ears? Yes No

Do you get headaches often? Yes No

Do you experience dizziness? Yes No

Do you experience tingling in your fingers? Yes No

Thank you for taking the time to fill out this form. To send this information click submit once. We will get back to you by phone either today or the next business day to set up your appointment.

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